Failure to Provide Behavioral Health Services Following Antipsychotic Medication Refusal
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident diagnosed with schizoaffective disorder, bipolar type, when the resident began refusing her prescribed antipsychotic medication, Zyprexa. The resident had a history of stable behavior while compliant with her medication regimen, but after refusing Zyprexa starting on 8/25/25, she exhibited a marked increase in aggressive and inappropriate behaviors, including yelling, anger outbursts, refusing care, and physical aggression toward staff and other residents. Despite these changes, the facility did not develop or implement a written, individualized plan of care to monitor or address the resident's behavioral health needs resulting from her medication refusal. The clinical record and interviews revealed that the resident's behavioral episodes escalated significantly after she stopped taking Zyprexa, with multiple incidents of screaming, anger outbursts, and physical aggression documented over several days. Staff interviews confirmed that the resident's baseline behavior was calm and non-aggressive prior to the medication refusal, and that the escalation in behavior was directly associated with the lack of antipsychotic medication. The facility's care plan for medication non-compliance was generic and did not address the specific risks or interventions needed for the resident's decompensation, nor did it include strategies for monitoring or preventing further behavioral escalation. Additionally, the facility did not convene an Interdisciplinary Team (IDT) meeting or revise the care plan in response to the resident's change in condition, despite multiple incidents of aggression and staff awareness of the situation. The facility's own policies required immediate safety strategies, individualized interventions, and timely care plan updates in response to significant changes in a resident's condition, but these actions were not taken. As a result, the resident was not adequately monitored or supervised, and interventions to prevent harm to herself and others were not implemented.